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JACKSON MEMORIAL HOSPITAL 1611 NW 12TH AVE MIAMI, FL 33136 April 30, 2014
VIOLATION: COMPLIANCE WITH 489.24 Tag No: A2400
Based on reviews of medical records, electronic e-mail, List of International Patients, Letter of Agreement and interviews, the facility failed to ensure the appropriate steps were completed to avoid any delay in further medical examination and treatment to inquire as to whether the individual is insured or type of insurance for 1 out of 20 Sampled Patients (SP) #1 needing further medical treatment for an identified emergency medical condition. Refer to findings in Tag 2408.
Based on reviews of medical records, policies and procedures, bed census report, physician on-call- list, State Operations Manual, Appendix V, and interviews, the facility failed to accept from a referring hospital, within the boundaries of the United States, an appropriate transfer based on financial clearance of an individual who required such specialized capabilities (Cardio-Thoracic Surgery) or facilities to treat an individual for 1 SP #1 (sampled patient) of 20 sampled patients. Refer to the findings in Tag 2411.
VIOLATION: DELAY IN EXAMINATION OR TREATMENT Tag No: A2408
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on reviews of medical records, electronic e-mail, List of International Patients, Letter of Agreement and interviews, the facility failed to ensure the appropriate steps were completed to avoid any delay in further medical examination and treatment to inquire as to whether the individual is insured or type of insurance for 1 out of 20 Sampled Patients (SP) #1 needing further medical treatment for an identified emergency medical condition.

The findings include:

SP #1's medical record was reviewed. Review of the Emergency Department Notes revealed the patient presented on April 6, 2014, Time 00:15 (12:15 a.m.). SP #1 presented to triage with mistral non-radiating chest pain rated at 7 on the pain scale (Pain scale of 0-10 with 10 being the highest). Documentation by the case manager on the case manager notes indicated that on 4/6/2014 at 12:14 p.m., " Pt's medical record forwarded to Jackson Memorial Medical Center who declined the transfer ...(consulting physician) informed SW (social worker ) that he contacted JVM (Jackson Memorial Hospital) once again to gain pt's acceptance; that he spoke to (on call cardiovascular surgeon) there who will discuss same with transfer center. 11:46 am telephone call to Assistant Director of Medicaid Program to request a letter of guarantee from JVM; message left regarding same and to return call. 11:59 a.m. the social summary was prepared and emailed to Assistant Director of Medicaid along with the completed authorization for special services form. ...1:09 P.M. Telephone call to Jackson Memorial Hospital (JVM); ______ physician name who explained to this SW pt's case cannot be reviewed or accepted until a letter of guarantee is forwarded to their facility from Commissioner. ..1:22 PM per Consulting physician, he was able to reach Commissioner. . . who voiced compliance in regards to completing the letter and forwarding same to Jackson Memorial Hospital. ...2:06 p.m. Received copy of the emailed letter from Commissioner.. forwarded to JVM. 2:10 p.m. Telephone call to physician at JVM who confirmed receipt of letter. However, physician maintained that his financial person ... has to review the letter tomorrow; that she is not at work today and will not come in to do so. Conveyed this information to consulting physician". The consulting physician documented, the patient's information was presented to Jackson Memorial Hospital's Transfer Center and was currently pending financial clearance. Jackson Memorial Hospital requested a (financial) clearance letter from the Commission of Health. The consulting physician documented, he called the commissioner at 1:19 PM today on April 6, 2014. The financial clearance letter was sent to Jackson Memorial Hospital. As soon as the patient is accepted, we will arrange ambulance (air ambulance) transfer to Jackson Memorial Hospital for possible emergency open heart surgery. SP #1 died in the transferring hospital emergency department at 00:33 AM on April 07, 2014, and was never accepted for transfer to Jackson Memorial Hospital pending financial clearance for payment.


Review of a copy of an electronic email provided to the survey staff/surveyors, dated 04/16/2014, and sent to the Supervisor of the International Department/International Transfer (Subject: FEW SP #1) Center revealed, a call was received on Saturday night 04/05/2014, from the International Coordinator advising us of this possible transfer and also the steps that he had taken with this case.

Review of the list of international patients provided by the Director of International Services revealed, SP#1 is listed as U.S. Virgin Islands [Medicaid], not financially cleared and the patient passed away.

Review of the Letter of Agreement dated 4/6/2014 written by the Commissioner, sent to hospital #2's managed care department, revealed the following, Name of SP#1, Diagnosis: Life-threatening ascending aorta dissection needs emergency open heart surgery with replacement of aortic valve and ascending aorta on bypass machine. The letter was sent by the Commissioner in an email (electronic mail) on 4/6/2014 (Sunday) at 1:59 p.m. This was sent to the Assistant Vice President of Managed Care and to the International Services at the hospital.

During an Interview with the Director of Patient Placement and Central Staffing on 04/28/2014 at 3:44 p.m., she stated that the transfer center is a group of clerks, and nurses. We get the clinical information about a patient; we enter the information in the system. The clinical information about the patient is reviewed by the Assistant Chief Medical Officer who determines if the patient can be helped by Jackson Memorial Hospital, if the services are available or not, and if the transfer is to be approved. If the transfer is approved, the bed is assigned, and what type of services the patient needs, the receiving doctor is informed. The transfer staff will call the facility transferring the patient. The report is done from the nurse of the referring facility to the nurse here at Jackson Hospital. The transportation is arranged by the referring facility. We do not do (referring to transportation) international patients.

During an interview with the Director of International Services (IS) conducted on 4/28/2014 at 1:55 PM. The IS stated, the patient's insurance is verified with the insurance company of the patient. The Director of International Services reported, we do not accept a transfer unless the patient is financially cleared from the insurance company. The ambulance does not leave the other country, unless the patient is financially cleared and has an accepting physician here. If the patient has no insurance and no money to pay at all, the transfer is not approved. No insurance, no money, no transfer and we inform the referring facility. Interview with the Director of International Services (IS) on 4/29/14 at 9:34 AM, it was reported, we go case by case. The Letter of Guarantee (LOG) was sent by the Commissioner on a Sunday, 4/6/14. We requested a letter because there is no contract. The Director of International Services reported, we can't do the financial clearance without the Letter of Guarantee. The call was placed on Saturday, April 5th and the International Coordinator called the Supervisor. The Letter of Guarantee needs to be reviewed and approved by the Assistant Vice President of Managed Care. The Director of International Services reported, Managed Care only works Monday to Friday. The DIS reported, the Social Worker from the USVI was aware that the Letter of Guarantee was to be reviewed on Monday, April 7 2014. On Monday, the call was made to the USVI to check on the patient and we learned that the patient had expired. The Letter of Guarantee was not read on Sunday. The Chief Administrative Officer asked about this case and I informed him that the case was presented on a Saturday and was not presented as critical. There were no written medical records provided. The letter was sent, but not reviewed on Sunday. The DIS reported, if there is a critical case, I can reach the Assistant Vice President of Managed Care on a weekend.

During an interview with the Assistant Vice President (VP) of Managed Care conducted on 4/29/2014 at 11:49 a.m. it was reported, I negotiate contracts domestically (within the United States and United States territories) and also provide financial assistance and clearance for international patients. It was then reported, we are a team of 10 and we work Monday to Friday. It was reported, I remember the Commissioner of the Virgin Islands sent a letter on a Sunday. We checked the letter first thing on Monday. It was further reported, I don't check my work emails on Sunday's. We have an open communication with the Commissioner. Usually, if it's urgent, I get a call. I did not receive a call from the Commissioner. I did not receive a call from International Services and they have access to my cell phone, if needed. I read from an email from the International Services, that the patient passed away. It is usually a quick process. I review the Letter of Guarantee and I give the financial clearance. I am now working with the Commissioner about a contract that would eliminate the Letter of Guarantee. I have not heard from the Commissioner about this case.

During an interview with the Supervisor at Jackson Memorial hospital on [DATE] at 1:48 PM it was reported, I received the call from the International Coordinator. The patient was a Medicaid patient from the United States Virgin Islands. I explained that the patient is a Medicaid case, we need a Letter of Guarantee from the Commissioner and the letter will be reviewed by Managed Care who will call back to give an answer. On Monday (04/07/2014), we learned that the patient passed when the hospital was called. The Supervisor at Jackson Memorial Hospital reported, I saw the letter from the USVI commissioner on 04/06/2014, the same day it came. I read it from my phone. The Supervisor stated, there is no protocol what to do next if the Assistant VP of Managed Care is not available and I do not have a telephone number for the Assistant VP of Managed Care. I didn't call the Director because she was out of town. During an interview with the Director of International Services on 4/30/2014 at 9:50 AM, it was reported that this process is only for Medicaid cases from the USVI since there is no contract at present.
When a request for transfer was made (Hospital #1) on 4/6/2014 for patient SP#1 to Jackson Memorial Hospital, the hospital failed to ensure that further medical examination and treatment is not delayed in order to inquire about the patient's method of payment or insurance. The hospital also failed to have an effective 24 hours/7days a week system/protocol in place to address life threatening transfers of domestic patients with identified emergency medical conditions.

During an interview with the Cardiac Surgeon from Jackson Memorial Hospital on April 30, 2014 at 2:30 PM, the cardiac surgeon reported, the Referring Physician texted him on April 6th that a letter was sent, but the financial clearance would be reviewed the next day. The Referring Physician asked the surgeon, if the financial clearance could be done that same day. The surgeon reported, he called the Transfer Center and was told they would look into it. The surgeon reported, late at night, I received a text message from the Referring Physician that the patient died .
VIOLATION: RECIPIENT HOSPITAL RESPONSIBILITIES Tag No: A2411
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY**

Based on reviews of medical records, policies and procedures, bed census report, physician on-call- list, State Operations Manual, Appendix V, and interviews, the facility failed to accept from a referring hospital within the boundaries of the United States an appropriate transfer based on financial clearance of an individual who required such specialized capabilities (Cardio-Thoracic Surgery) or facilities to treat an individual for 1 SP #1 (sampled patient) of 20 sampled patients.
The Findings are:

The facility's policy indicated in part, "It is the policy of the Public Health Trust (PHT) that transfers between Jackson Health System (JHS) hospitals . . . and other U.S. (United States) hospitals including those patients with emergency medical conditions will be managed and documented in accordance with appropriate medical standards of care. . .Definitions: A. Accepting JHS Physician ...2. For transfer requests for ER (emergency room ) evaluation from another hospital's emergency department of a patient beyond the capability of the other hospital's emergency department ...where the patient requires emergency medical screening or evaluation and decision-making, the accepting physician is the emergency physician and attending of the relevant service requested ...B. Emergency Medical Condition: A medical condition manifesting itself by acute symptoms of sufficient severity, which may include severe pain, such that the absence of immediate medical attention could reasonably be expected to result in any of the following: 1. Placing health of the individual ...in serious jeopardy; or 2. Serious impairment of bodily functions or: 3. Serious dysfunction of any bodily organ or part ...E Service Capability: the types of medical services the hospital provides (e.g. surgery ...intensive care ...trauma care) within the training, scope, licensure and certification of its staff ... F. Services Capacity: Services capacity encompasses such things as number and availability of qualified beds, physical space, and equipment and supplies .....B. Transfer of patients to JHM ... 2. (C) If there is capacity and the transfer is accepted by the appropriate Accepting JHS Physician, the JMH Transfer Center (or corresponding departments) ... shall complete the transfer form, make all the necessary internal arrangements and notify the charge nurse of the pertinent treatment area in the ER's or in patient unit. "All request for emergency transfers to the hospital, other than involuntary, mental health, or trauma transfers, shall be routed through the hospital transfer center.
State Operations Manual, Appendix V (5) Interpretive Guidelines- Responsibilities of Medicare Participating Hospitals in Emergency cases ... 489.24 (f) Recipient Hospital Responsibilities ... Interpretive guidelines: ...In accordance with Section 210(i) of the Social Security Act, the term "United States," when used in a geographical sense, means the States, the District of Columbia, the Commonwealth of Puerto Rico, the Virgin Islands, Guam and American Samoa."
Patient #1's medical record from the referring hospital was reviewed. Review of the emergency room record dated April 6, 2014 revealed the patient (SP#1) was [AGE] year old and the Insurance Carrier was listed as "Self-Pay." A review of the "emergency room Physician-Chest Pain" form dated April 6, 2014 revealed that SP#1's Chief Complaint was chest pain, onset days ago, and timing was listed as sudden and constant. SP#1's pain was listed as severe and the quality of the pain was "sharp" and "tearing". The associated symptoms were listed as sweating (Diaphoresis) and shortness of breath. SP #1 also complained of back pain. The physicians order sheet revealed that an intravenous line was started with Normal saline at 125 cc/ hr. (hour), cardiac monitor, pulse oximetry (a device that monitors the percentage of oxygen circulating in the blood), oxygen at 2 liters, a stat portable chest x-ray was also ordered. The medications administered to SP#1 were aspirin (blood thinner), Morphine (pain medication) intravenously and Zofran (anti-nausea medication). Further review indicated that a CT scan (Computed Tomography scan uses x-rays to make detailed pictures of structures inside of the body) was ordered. The medical record indicated that the ED physician discussed the results of the CT scan with the radiologist, "Type A dissection (Aortic dissection: occurs when a tear in the inner wall of the aorta causes blood to flow between the layers of the wall of the aorta causes blood to flow between the layers of the wall of the aorta, forcing the layers apart in most cases this associated severe characteristic chest.. Pain described as "tearing" in character, and often with other symptoms that result from deceased blood supply to other organs. Aortic dissection is a medical emergency) with Thrombus." Further review indicated that at 0:615 a.m. "calling Miami"; at 06:30 am the physician at Jackson states they don't take Medicaid from Virgin Islands. Review of the Consultation Report dated April 6, 2014 indicated in part, "The patient was seen at 10 a.m., History of Present illness: this patient ... who presents to the emergency room with a chest pain since yesterday. He has a history of aortic valve insufficiency ... I was consulted to evaluate the patient and transferring him to cardiovascular open-heart surgical center ... Past Medical History: 1. Aortic insufficiency (is a heart disease in which the aortic valve does not close tightly. This leads to the backward flow of blood from the aorta (a large blood vessel) into the left ventricle (a chamber of the heart.); 2. Hypertension (High blood Pressure) ... Physical Examination: VITAL SIGNS: Blood Pressure is between 121-140/57-68 on Esmolol drip (Antiarrhythmic- medication used to suppress abnormal rhythms of the heart) as well as Nipride drip (a vasodilator (means to open up blood vessels) which is used to lower blood pressure). NEURO: The patient is awake, alert and oriented x 3 ... CARDIOVASCULAR: ...regular rate ad rhythm ... ASSESSMENT AND PLAN: ... acute ascending aorta type A aortic. The patient requires emergency transfer to a cardiothoracic surgery and vascular surgery sent down for open-heart surgery with most likely replacement of aortic valve (a valve located between the Aorta and the left ventricle that prevents the backflow of blood into the left ventricle) ... We initiated transfer to Territory Center (Jackson Memorial Hospital) with capacity for open -heart surgery and vascular surgery. ..I presented the case to Jackson Memorial Hospital in Miami. I spoke to (Cardio thoracic surgeon on-call) heart surgeon this morning at 11:24 a.m. on April 6, 2014. He/ She merely accepted the patient from the surgical point of view. The patient was presented to the Jackson Memorial Hospital Transfer Center and is currently pending financial clearance." The Code Blue Critical Care Note dated 4/7/2014 was reviewed. The note specified in part, Code Blue (hospital code used to indicate a patient requiring immediate resuscitation) was called shortly after midnight because the patient became unresponsive and was in pulseless electric activity (is a clinical condition characterized by unresponsiveness and lack of a palpable pulse), responded to the Code Blue situation. The patient was not breathing, had chest exposed ... he was pulseless...was monitored... CPR (Cardiopulmonary Resuscitation-Chest compressions) initiated. The patient was ambu bag ventilator FIO2 (oxygen) at 100%, epinephrine (medication used for immediate elevation of blood pressure) 1 mg IV push was given .... The patient continued to have ongoing chest compression. He was endotracheal intubated (insertion of flexible breathing tube into the windpipe to maintain an open airway) ...We continued with resuscitation efforts, however, unfortunately the patient continued to be in pulseless electrical activity and subsequently went into asystole (no heart beat). He could not be resuscitated and expired out 00:33 a.m. on April 7, 2014." The hospital failed to ensure that their policy and procedure was followed as evidenced by failing to accept: 1.) an emergency transfer from a referring hospital within the boundaries of the United states who lacked Cardiothoracic surgery capability and capacity for SP#1 on April 6, 2014; 2.) an individual (SP#1) with an identified emergency medical condition manifesting itself by acute symptoms of sufficient severe and tearing chest pain, shortness of breath and sweating, placing the individual's health in serious jeopardy.
The on call Cardio Thoracic surgery schedule was reviewed. Review of the on call schedule verified that on April 6, 2014. Jackson Memorial Hospital had service capability, a cardiothoracic surgeon and cardiothoracic surgery service was available on April 6, 2014 for SP #1.
The Custom Census Report w/ (with ) select nursing stations for patient placement dated April 6, 2014 was reviewed. Review of this report revealed the following: 1. The Coronary care unit had 11 occupied beds and 2 available beds; The Medical Intensive Care Unit had 13 occupied beds and 7 beds available; The 9ICB (ICU-Intensive Care Unit) had 17 occupied beds and 5 beds available; and the Surgical Intensive Care Unit had 10 occupied beds (In-Pt (patient) and 14 beds available. On April 6, 2014, Jackson Memorial Hospital had service capacity as evidenced by available qualified beds, physical space and equipment and supplies for SP#1.
During an interview with the Director of International Services (DIS) conducted on 4/28/2014 at 1:55 PM it was reported, we deal with international patients, and guest services. Patients are airlifted from other countries, including those who are outpatient cases. A call is received by the International Coordinator (IC). The financial information, clinical information about the patient, and medical records are requested from the other country. After the International Coordinator speaks to the patient's physician and gets a better understanding of the patient's clinical needs, the case is presented to the right service to get an accepting MD (Medical Doctor). The Director of International Services reported, recently there was an incident, the patient died and he was from the United States Virgin Islands (USVI).This interview further validates that the facility failed to follow their policy and procedure related to accepting transfers of individuals with an identified emergency medical condition within the boundaries of the United States.